Longitudinal association of exclusive and dual use of cigarettes and cigars with asthma exacerbation among US adults: a cohort study.

BACKGROUND: Cigar use among adults in the United States has remained relatively stable in the past decade and occupies a growing part of the tobacco marketplace as cigarette use has declined. While studies have established the detrimental respiratory health effects of cigarette use, the effects of cigar use need further characterization. In this study, we evaluate the prospective association between cigar use, with or without cigarettes, and asthma exacerbation. METHODS: We used data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study to run generalized estimating equation models examining the association between time-varying, one-wave-lagged cigarette and cigar use and self-reported asthma exacerbation among US adults (18+). We defined our exposure as non-established (reference), former, exclusive cigarette, exclusive cigar, and dual use. We defined an asthma exacerbation event as a reported asthma attack in the past 12 months necessitating oral or injected steroid medication or asthma symptoms disrupting sleep at least once a week in the past 30 days. We adjusted for age, sex, race and ethnicity, household income, health insurance, established electronic nicotine delivery systems use, cigarette pack-years, secondhand smoke exposure, obesity, and baseline asthma exacerbation. RESULTS: Exclusive cigarette use (incidence rate ratio (IRR): 1.26, 95% confidence interval (CI): 1.03-1.54) and dual use (IRR: 1.41, 95% CI: 1.08-1.85) were associated with a higher rate of asthma exacerbation compared to non-established use, while former use (IRR: 1.01, 95% CI: 0.80-1.28) and exclusive cigar use (IRR: 0.70, 95% CI: 0.42-1.17) were not. CONCLUSION: We found no association between exclusive cigar use and self-reported asthma exacerbation. However, exclusive cigarette use and dual cigarette and cigar use were associated with higher incidence rates of self-reported asthma exacerbation compared to non-established use. Studies should evaluate strategies to improve cigarette and cigar smoking cessation among adults with asthma who continue to smoke.

Cross-sectional patterns and longitudinal transitions of unflavored and flavored cigar use without and with cigarettes among United States adults.

INTRODUCTION: Over half of US adults who smoke cigars use flavored cigars, illustrating their broad appeal; however, their long-term impact on cigar and cigarette use is unknown. METHODS: Using restricted data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, we investigated cross-sectional patterns and longitudinal transition rates of unflavored and flavored cigar use with and without cigarettes among a nationally representative sample of US adults. RESULTS: Proportionally, more adults who used flavored cigars without or with cigarettes were younger and female. More adults with exclusive cigar use were non-Hispanic Black. More adults with dual use had lower educational attainment. The median number of cigars smoked daily and tobacco dependence was highest among adults who used flavored cigars with cigarettes. Only 14.6% of adults with exclusive flavored cigar use at Wave 1 continued their use to Wave 5, with most transitioning to non-current (46.4%) or exclusive cigarette use (22.9%). Likewise, 13.8% of adults with dual flavored cigar and cigarette use at Wave 1 continued their use to Wave 5, with 57.6% transitioning to exclusive cigarette use and 19.7% transitioning to non-current use. Comparatively, 72.9% of adults with exclusive cigarette use continued their use to Wave 5, while 23.6% transitioned to non-current use. CONCLUSION: Adult cigar use was less stable than cigarette use, particularly among those who use flavored cigars. Future research should investigate whether these transition patterns between flavored and unflavored cigar and cigarette use vary across sociodemographic groups and their potential long-term health implications.

Blunt smoking during emerging adulthood: Characterizing transitions in cannabis and cigar co-use among a diverse cohort in Texas.

OBJECTIVE: To characterize and compare transitions in blunt smoking behaviors among a diverse cohort of youth and young adults observed between Spring 2019 and Fall 2021. METHODS: We analyzed n = 14,152 observations (i.e., completed surveys) provided by n = 2,610 youth and young adults over six (6) waves from Spring 2019 to Fall 2021 via the Texas Adolescent Tobacco and Marketing Surveillance (TATAMS) system. Participants were recruited in age-cohorts, reflecting 16.5 years (0.5), 18.5 years (0.6), and 20.1 years (0.8) of age at baseline. We applied a three-state Markov model to estimate blunt initiation (never â†’ ever), onset (never â†’ current), continuation (ever â†’ current), and discontinuation (current â†’ ever). First, we compared transitions in blunt smoking by race/ethnicity, with non-Hispanic (NH) Whites as the referent. Second, we stratified the Markov models by race/ethnicity to identify common and unique predictors of blunt transitions, including sex, age, alcohol use, depression, anxiety, and tobacco cigar smoking. RESULTS: At baseline, 73% of participants had never smoked blunts, 15.3% had ever smoked blunts s, and 11.7% currently smoked blunts. NHB (HR: 2.15; 95% CI: 1.21-3.84) and Hispanic (HR: 1.72; 95% CI: 1.08-2.72) participants had significantly greater risk of blunt smoking initiation, relative to NHWs. Similarly, NHBs had great risk for continuation (HR: 1.65; 95% CI: 1.16-2.34) and lower risk of discontinuation (HR: 0.57; 95% CI: 0.42-0.77), relative to NHWs. Alcohol use predicted greater risk for onset among NHW (HR: 5.22; 95% CI: 1.40-19.45), NHB (HR: 3.14; 95% CI: 1.32-7.46), and Hispanic (HR: 2.99; 95% CI: 1.80-4.97) participants. CONCLUSIONS: Blunt smoking initiation was most common among NHB and Hispanic youth and young adults while risk for sustained blunt smoking was higher in NHB youth and young adults. Research and interventions should investigate the link between alcohol use and elevated blunt smoking among young people.

Come for the Tobacco, Stay for the Flavor: Flavored Cigarillo-Use Trajectories Among Young Adult Sexual Gender Minority Women.

INTRODUCTION: The purpose of this research was to identify how young adult sexual gender minority (SGM) women who use cigarillos may respond to cigar flavor restrictions. AIMS AND METHODS: Young adults aged 21-28 years in the United States who currently use cigarillos were recruited between October 2020 and April 2021 to participate in an online survey. Due to high prevalence of cigarillo use among individuals who identify as sexual and/or gender minority (SGM) women, their (n = 192) flavored tobacco-use behaviors and anticipated responses to cigarillo flavor restrictions were compared to cisgender heterosexual (CisHet) women (n = 110). Logistic regression was used to model cigarillo cessation and product-switching behaviors (flavored and unflavored). RESULTS: SGM women were significantly less likely to report the use of flavor at the initiation of cigarillo use (61.7% vs. 86.1%) but were no different in current flavor use compared to CisHet women, with more than 80% of all women using any flavor. SGM women were 2.36 times as likely to say they would discontinue using cigarillos if flavors were unavailable. Among those who would continue using cigarillos, SGM women were 4.53 times as likely to endorse switching to an unflavored tobacco product but had the same likelihood of saying they would switch to flavored product compared to CisHet women. CONCLUSIONS: Flavor restriction policies may not reduce the initiation of cigarillos among SGM women and may elicit differential cigarillo use and tobacco product substitution by SGM identity. Flavor restriction policies should be coupled with targeted cessation resources to address potential remaining disparities. IMPLICATIONS: SGM US women have a unique cigarillo-use trajectory. These women are more likely to initiate cigarillos without flavor and then later integrate it into their behavior. National cigar flavor restrictions are expected to have a greater impact decreasing cigarillo initiation among CisHet women and decreasing current cigarillo use among SGM women. However, for those who would continue using unflavored cigarillos, SGM women may remain at risk for nicotine dependence due to increased product substitution. SGM women should be prioritized for cessation resources to reduce tobacco-use disparities leading up to and following the implementation of cigar flavor restrictions.

Respiratory symptoms and outcomes among cigar smokers: findings from the Population Assessment of Tobacco and Health (PATH) study waves 2-5 (2014-2019).

BACKGROUND: The mechanisms by which cigarette smoking increases the risk of respiratory disease have been studied. However, less is known about risks of respiratory symptoms and outcomes associated with smoking cigars, and risks by cigar types have not been previously explored. The aim of this study was to examine associations between cigar use, including traditional cigars, cigarillos, filtered cigars, and dual cigar and cigarette use, and functionally important respiratory symptoms (FIRS), lifetime asthma diagnosis, uncontrolled asthma, and new cases of FIRS. METHODS: Data from Waves 2-5 (2014-19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal study, were analyzed in two ways. For cross-sectional analysis, the analytic sample included adults 18 and older at each wave, resulting in 44,040 observations. Separately, longitudinal analyses were assessed among adults 18 and older at Wave 2, resulting in 7,930 individuals. Both analyses excluded adults with chronic obstructive pulmonary disease (COPD) or non-asthma respiratory disease. RESULTS: Current established cigarillo smokers had higher odds of having FIRS (Adjusted odds ratio (AOR): 1.72; 95% CI: 1.08, 2.74) compared to never smokers of cigarillos and cigarettes, after adjusting for covariates. Current established filtered cigar smokers had higher odds of asthma diagnosis (AOR: 1.35; 95% CI: 1.10, 1.66) while current established dual smokers of filtered cigars and cigarettes had higher odds of uncontrolled asthma (AOR: 5.13; 95% CI: 1.75, 15.02) compared to never smokers of filtered cigars or cigarettes. Both current established cigar smokers and current established dual smokers of cigarettes and cigars had higher odds of new FIRS compared to never cigar or cigarette smokers (AORs: 1.62; 95% CI: 1.02, 2.60 for exclusive cigars and 2.55; 95% CI 1.57, 4.14 for dual smokers). CONCLUSIONS: This study provides evidence that cigar smokers or dual smokers of cigars and cigarettes have greater odds of FIRS, asthma, and uncontrolled asthma and that new incidence of FIRS is higher among any cigar smokers compared to never cigar or cigarette smokers. Understanding health impacts associated with cigar use provides information for supporting policy development, as well as for designing clinical interventions focused on smoking cessation for cigars.

Examining Demand and Substitutability of Usual Brand Little Cigars/Cigarillos and Cigarettes in Young Adults Who Dual Use.

INTRODUCTION: Cigarette and little cigar/cigarillo (LCC) dual use is popular among young people and poses a substantial health risk. What remains unclear is the abuse liability of LCCs vs. cigarettes, LCCs' substitutability for cigarettes, and the influence of flavors on the abuse liability and substitutability of LCCs. METHODS: Sixty-five young adults (18-34 years) who dual use completed hypothetical purchase tasks to measure consumption of usual brand cigarettes and LCCs in 24 hours at increasing prices (demand), and LCC consumption at increasing cigarette prices (substitution). Three demand indices were calculated from raw data: breakpoint (price after which consumption reaches 0), Omax (maximum daily expenditure), and Pmax (price at maximum expenditure). Two indices were estimated using nonlinear mixed-effects modeling: intensity (consumption when free) and price-sensitivity (rate of decline in consumption as price increases). Substitution, and associations of flavored use with demand and substitution, were estimated using linear mixed models. RESULTS: Results indicated similar abuse liability for LCCs and cigarettes. Intensity was greater for cigarettes, but price-sensitivity was similar. Flavored LCC use was associated with lower price-sensitivity and greater intensity than unflavored. LCCs were significant substitutes for cigarettes, but the effect was small. Flavored use was not associated with substitution. CONCLUSIONS: Among young adults who dual use, LCCs and cigarettes had similar abuse liability, and those who used flavored had higher demand for their LCCs. A flavored cigar ban, as well as targeted prevention and cessation services for those who smoke flavored LCCs, may be important for reducing dual use in young adults. IMPLICATIONS: Cigarette and LCC dual use remains high among young adults. Using hypothetical purchase tasks with young adults who dual use, LCCs had abuse liability similar to cigarettes, but were only modest substitutes for cigarettes. Participants who used flavored LCCs reported greater abuse liability than those who used unflavored, but not greater substitution for cigarettes. Prevention and cessation services are needed to target LCCs in young people, particularly those smoking flavored products. A flavored cigar ban may help to reduce their demand.

A Longitudinal Analysis of Flavored Cigar Use and Cigar Smoking Cessation Among US Adults.

BACKGROUND: Flavorings in cigars increase their appeal, mask the harsh taste of tobacco, and may hinder successful cigar smoking cessation; however, limited evidence has examined whether flavors are associated with short- or long-term cigar smoking cessation. AIMS AND METHODS: Using restricted data from the Population Assessment of Tobacco and Health Study Waves 1-5, we examined whether flavored cigar use was associated with 30-day-plus and 1-year-plus cigar smoking cessation among US adults. Multivariable discrete-time survival models were fit to a nationally representative sample of US adult (18+) respondents who had a current, established cigar use, smoked five or more days in the past 30 days, and did not exclusively smoke traditional premium cigars at baseline. Models adjusted for age, sex, race and ethnicity, income, cigar and cigarette smoking intensity, and blunt use. RESULTS: At baseline, 44.6% of respondents (n = 674) were 18-34 years old, 75.0% were male, 56.7% were non-Hispanic White, 78.9% had household incomes of <$50,000, and 56.2% smoked flavored cigars. In fully adjusted models, flavored cigar use was associated with a lower risk of 30-day-plus (HR = 0.76, 95% CI = 0.60, 0.97) but not 1-year-plus cigar smoking cessation (HR = 0.81, 95% = 0.62, 1.05). CONCLUSIONS: We found that flavored cigar use was associated with a lower risk of short-term but not long-term cigar smoking cessation. More work is needed to understand the dynamics of cigar smoking transitions, including initiation, cessation, and relapse, particularly in larger cohorts and among those who exclusively use cigars or dual-use cigars and cigarettes. IMPLICATIONS: As local and some state jurisdictions continue to adopt partial or complete bans of flavored cigar products and the United States Food and Drug Administration considers a national ban of all characterizing flavors in cigars, there is a need for more longitudinal work examining the associations between flavorings in cigars and short and long-term cigar-smoking behaviors, including but not limited to initiation, cessation, intensity of use, and relapse, particularly in diverse cohorts.

Trends and Associations of Past-30-Day Cigar Smoking in the U.S. by Age, Race/Ethnicity, and Sex, NSDUH 2002-2020.

Cigar smoking remains a public health issue in the United States (U.S.), with a heterogeneous prevalence based on sociodemographic characteristics. Nationally representative data suggest changes in cigar smoking over time, with some evidence for sociodemographic differences. Using data from the 2002-2019 National Survey on Drug Use and Health (NSDUH), the prevalence of past-30-day cigar smoking was examined overall and stratified by sociodemographic characteristics; joinpoint regression examined the trends. Logistic regression analyses identified the correlates of cigar smoking using 2020 NSDUH data. From 2002 to 2004, the prevalence of cigar smoking remained stable (5.33-5.73%), but declined from 2004 to 2019 (5.73-4.29%). Cigar smoking declined in some periods between 2002-2019 among the non-Hispanic White, Hispanic, ages 12-17, ages 18-20, ages 21-25, age ≥ 35, and male subgroups, but remained unchanged among the non-Hispanic Other, ages 26-34, and female subgroups. Cigar smoking increased among non-Hispanic Black persons overall from 2002 to 2019 (6.67-8.02%). Past-30-day cigarette smoking and drug or alcohol use disorder was associated with an increased likelihood of cigar use, while female sex was associated with a decreased likelihood of cigar use, across all age groups. Though a decline in the prevalence of past-30-day cigar smoking is seen in the general population, the same is not evident among all sociodemographic subgroups. Our findings have the potential to inform tobacco cessation efforts within clinical practice, as well as regulatory efforts to reduce cigar use.

Evaluating Correlations Between Premium Cigar Smoking and Mental Health and Substance Use Dependence Conditions Among U.S. Adults, 2010-2019.

INTRODUCTION: Improved understanding of health conditions associated with premium cigar smoking can inform efforts to reduce cigar use. This paper extends findings commissioned for the National Academies of Science, Engineering, and Medicine report on premium cigars. AIMS AND METHODS: We pooled 2010-2019 National Survey on Drug Use and Health data to evaluate cross-sectional associations between premium cigar smoking and mental health and substance use conditions among U.S. adults. A series of logistic regression models adjusted for age, sex, race and ethnicity, cigarette smoking, and alcohol consumption compared odds of each condition associated with past-month premium cigar smoking relative to past-month nonpremium cigar smoking, never tobacco use, and current established cigarette smoking. RESULTS: Premium cigar smoking was associated with lower adjusted odds of past month serious psychological distress, past year major depressive episode, and cannabis and illicit drug dependence relative to nonpremium cigar and cigarette smoking; however, higher odds of alcohol and cannabis dependence were observed relative to never tobacco use, and lower odds of alcohol dependence were observed relative to current cigarette smoking but not current nonpremium cigar smoking. CONCLUSIONS: We observed considerable variation in both magnitude and direction of associations between premium cigar smoking and mental health and substance use indicators depending on the condition and reference group to which premium cigar smoking was compared. IMPLICATIONS: Premium cigar smoking frequently cooccurs with cigarette smoking and alcohol consumption, thus potential health correlates must be considered in appropriate context. We observed considerable variation in direction and magnitude of association depending on the health condition and reference population, as well as potential for reverse causality and residual confounding in this cross-sectional analysis. As the tobacco landscape continues to evolve, rigorous scientific studies that incorporate clear differentiation of cigar type, measures of cumulative use, and temporal data collection are necessary to fully evaluate the health effects of premium cigar smoking and effectively inform Food and Drug Administration regulation.

Estimating Prevalence of Premium or Traditional Cigar Use and User Characteristics Based on Varying Definitions of Use.

BACKGROUND: Premium cigar use is infrequent compared with the use of other tobacco products, including other cigar types (eg, cigarillos), though current measurement methods for premium cigar use have limitations. Accordingly, prevalence estimates from existing surveillance studies likely underestimate the true prevalence of premium cigar use. AIMS AND METHODS: Using an online convenience sample of adults (ages 18-45 years) surveyed in February 2022, we examined premium or traditional cigar prevalence and characterized users based on four definitions of use: (1) past-year use, (2) past 30-day use, (3) use every day or some days, and (4) use every day, some days, or rarely, using a novel, one-item measure. We examined demographics, cigar use behaviors, and other tobacco product use for each definition and conducted sensitivity analyses using cigar brands. RESULTS: Prevalence estimates ranged from 1.8% using Definition 3 to 11.6% using Definition 1. Regardless of definition, premium or traditional cigar users were largely male, white, and aged 25-45 years. A large proportion of users based on Definition 3 were aged 25-34 years, had a regular premium cigar brand, smoked cigars on more than one day in the past month, used cannabis in the past month, and reported perceiving premium cigars as less harmful compared with cigarettes. DISCUSSION: Prevalence estimates of premium or traditional cigar use varied by more than fivefold based on the definition of use and user characteristics varied by definition. Existing national surveys are likely underestimating the prevalence and patterns of premium cigar use. IMPLICATIONS: Given that the negative health effects of premium cigars vary based on how the cigars are used (eg, frequency or duration), as well as co-use with other tobacco products and substances (eg, alcohol and cannabis), accurate measurement of these products is important for understanding patterns of use and their impact on public health.

Cross-sectional Use Patterns and Characteristics of Premium Versus Non-Premium Cigar Smokers in the United States, 2010-2019.

INTRODUCTION: Few studies have addressed the use patterns and characteristics of the past 30 days of premium versus non-premium cigar smokers. AIMS AND METHODS: We pooled 10 years of data from the National Survey on Drug Use and Health (NSDUH; 2010-2019) to evaluate use patterns and demographic and tobacco use characteristics of premium and non-premium cigar smokers ages 12 years and older in the U.S. cigar-type was manually coded as premium or non-premium according to the brand used most often. RESULTS: Between 2010 and 2019, 4.7% (95% CI = 4.6-4.8) of individuals aged 12 and older currently smoked cigars (past-30-day use). Smoking premium cigars (0.9% [95% CI = 0.8-0.9]) was less prevalent than smoking non-premium cigars (3.0% [95% CI = 2.9-3.1]). Although current non-premium cigar smoking prevalence steadily declined over the years, current premium cigar smoking prevalence remained stable. Premium cigar smokers were more likely to be older (≥25 years), male, non-Hispanic white, heterosexual, college educated, living in a large metro area, and to have income above 200% of the poverty threshold compared to non-premium users (p < .05). Additionally, past-30-day premium cigar smokers were less likely than non-premium users to initiate cigar smoking before the age of 18 years, smoke cigars frequently or daily, smoke cigarettes, or use marijuana (p < .05). CONCLUSIONS: Overall, premium cigar smoking is less prevalent than non-premium cigar smoking, especially among populations such as youth, racial/ethnic and sexual minorities, and low socioeconomic individuals. Premium cigar smokers tend to smoke infrequently and initiate cigars later in life compared with non-premium smokers. Study results can inform recommendations for regulating premium cigars. IMPLICATIONS: This study found that between 2010 and 2019, there are meaningful differences in the use patterns and characteristics of past-30-day premium versus non-premium cigar smokers in the United States. Premium cigars comprise a small share of the market compared to other cigar types and are less likely to be used by youth and other tobacco control priority groups (eg, racial/ethnic minorities and individuals with low socioeconomic statuses) that bear a disproportionate burden of risk and harm from using tobacco products. Additionally, most premium cigar users smoke them only occasionally. However, it is important to continue to monitor premium cigar use, as these patterns could shift because of factors like changes in marketing practices, consumer awareness, and product prices. Tobacco policy changes may also alter the patterns and trends of premium cigar use over time. A greater, more comprehensive understanding of premium cigars' physical characteristics, patterns of use, user perceptions, tobacco industry marketing strategies, and health effects will together help to inform cigar-related regulations.

Examining Cigar Pack Quantity Purchases by Cigar Type in the United States Between 2014 and 2017.

INTRODUCTION: We examined whether the proportion of cigar pack quantity usually purchased differed between 2014 and 2017 in the United States. METHODS: Data are from waves 1 and 4 of the Population Assessment of Tobacco and Health Study. The proportions of pack quantity purchases between waves for premium cigars, large cigars, cigarillos, and filtered cigars for 10-pack quantities (singles, 2-packs, 3-packs, 4-packs, 5-packs, 6-9-packs, 10-packs, 11--19-packs, 20-packs, ≥21 packs) were compared using Z-tests. We used multivariable linear regressions to examine factors associated with pack quantity. RESULTS: For premium cigars, most adults purchased singles, with 84.4% in 2014 and 88.7% in 2017. For large cigars, single purchases increased from 46.2% to 62.7% (p < .00001). Two-packs also increased, 3.1% to 10.2% (p < .00001), while 5-packs, 6-9 packs, 10-19-packs, and 20-packs decreased. For cigarillos, singles purchases increased from 51.9% to 57.5% (p = .0002). Two-packs also increased, 8.8% to 19.6% (p < .00001), while 3-packs, 4-packs, 5-packs, and 20-packs decreased. For filtered cigars, the most prevalent pack quantity shifted from 20-packs in 2014 (62.6%) to singles in 2017 (36.7%). Singles, 2-packs, 3-4-packs, and 5-packs increased while 11-19-packs, 20-packs, and ≥21 packs decreased. Days used were positively associated with pack quantity purchase for all cigar types in 2017, while the price was positively associated with premium cigar purchase. CONCLUSIONS: Between 2014 and 2017, the proportion of consumers who purchased singles remained at over 80% for premium cigars and increased for other cigars. Continued monitoring of use behaviors, including pack quantities by cigar type, is needed as the market and policy landscapes continue shifting. IMPLICATIONS: Single cigar purchases are prominent across cigar types. Five-packs and 20-packs were the second most common pack quantities across cigar types, with relatively low proportions for other pack quantities. These findings suggest adults consuming premium cigars consistently prefer singles, a pattern that was found across cigar types. However, when considering purchases made online, premium cigars are widely purchased in larger pack quantities. Age and race were associated with purchase for some cigar types at some years, days used were associated with the purchase quantity in 2017 for all cigar types, and price was positively associated across time periods for only premium cigar purchases. Thus, the factors associated with cigar pack quantity purchase remain unclear. As the cigar policy landscape shifts, continued monitoring of the purchase behaviors by cigar type will be important to better inform future cigar policies.

Patterns of Premium and Nonpremium Cigar Use in the United States: Findings from Wave 6 (2021) of the Population Assessment of Tobacco and Health Study.

INTRODUCTION: Understanding the characteristics of premium cigar use patterns is essential for minimizing public health harms. Typically, premium cigars are handmade, larger, more expensive, and without the characterizing flavors that are present in other cigar types: Nonpremium traditional cigars, cigarillos, and filtered cigars. AIMS AND METHODS: Self-reported brand and price data were used from Wave 6 of the Population Assessment of Tobacco and Health (PATH) Study to define and estimate premium versus nonpremium cigar use among U.S. adults, as well as to explore cigar smoking patterns, purchasing behavior, and reasons for use by cigar type. RESULTS: In 2021, 0.9% (95% CI = 0.7-1.0) of adults were premium cigar users, compared to 0.4% of nonpremium traditional cigar users (95% CI = 0.3-0.5), 1.1% of cigarillo users (95% CI = 1.0-1.2), and 0.6% filtered cigar users (95% CI = 0.5-0.7). Premium cigar users were overwhelmingly male (97.7%), and 35.8% were aged ≥55 years. The average premium cigar price/stick was $8.67, $5.50-7.00 more than other cigar types. Compared to other cigar types, significantly fewer premium cigar users had a regular brand with a flavor other than tobacco (~15% vs. 38%-53%). Though flavors remained the top reason for premium cigar use, they were less likely to endorse flavors as a reason for use than other cigar users (~40% vs. 68-74%). Premium cigar users had a lower prevalence (aRR: 0.37, 95% CI = 0.25-0.55) of dual use of cigars and cigarettes. CONCLUSIONS: Although <1% of U.S. adults use premium cigars, their use and purchasing characteristics continue to differ from other cigar types, highlighting the importance of capturing data specific to premium cigar use. IMPLICATIONS: This manuscript extends previous research from the National Academies of Science, Engineering, and Medicine report, "Premium cigars: Patterns of use, marketing, and health effects" by utilizing the most recent PATH Study data (Wave 6) to examine patterns of cigar use, including purchasing behavior and reasons for use, by cigar type (eg, premium traditional cigars, nonpremium traditional cigars, cigarillos, and filtered cigars). The findings support continued research on patterns of premium cigar use, which differ from use patterns of other cigar types.

Premium and Non-Premium Cigar Use Among a Nationally Representative Sample of Reproductive Age Women: Findings from the 2010-2019 National Survey on Drug Use and Health.

INTRODUCTION: Little is known about cigar use among women of reproductive age, especially potential differences relating to the use of premium versus non-premium cigars. AIMS AND METHODS: Using 2010-2019 data from the National Survey on Drug Use and Health, rates and trends in premium and non-premium cigar use were determined among women of reproductive age (18-49; n = 5651). Weighted sociodemographic characteristics, substance co-use, patterns of use, and health indicators were compared between women using premium versus non-premium cigars. RESULTS: Among reproductive-aged women who smoked cigars in the past 30 days, 4.9% reported use of premium cigar brands. The most commonly used premium brands were Romeo y Julieta, Cohiba, and Macanudos. Women who used premium versus non-premium cigars were less likely to identify as non-Hispanic black (16.5% vs. 35.5%), more likely to have household income >$50 000 (54.2% vs. 26.6%), and less likely to report past 30-day marijuana (28.7% vs. 55.7%) or blunt use (26.0% vs. 53.9%; ps < .001). Women who used premium cigars also reported later age of onset of cigar use (24.1 vs. 20.3 years; p < .001) and smoked fewer cigars in the last 30 days (9.8 vs. 2.3 days; p < .001). Trend analysis revealed that although rates of past 30-day premium cigar use remained consistent from 2010 (4.7%) to 2019 (4.9%), prevalence decreased from 6.6% in 2017 to 2.8% in 2018 before increasing to 4.9% in 2019. CONCLUSIONS: Understanding premium and non-premium cigar use among reproductive-age women, an understudied vulnerable population, will provide critical data to the Food and Drug Administration to inform policy and regulatory decisions. IMPLICATIONS: The current study revealed prevalence of ~5% premium cigar use among women of reproductive age who smoke cigars, and evidence for consistency in women's rates of premium cigar use across time. Women who used premium versus non-premium cigars were more likely to identify as non-Hispanic white, older, and of higher socioeconomic status were in better health and less likely to co-use cigarettes and marijuana, but more likely to co-use alcohol. Consideration of reproductive age and pregnant women as uniquely vulnerable populations is warranted in the development of regulations regarding premium and non-premium cigars. Comprehensive regulation of cigars (both premium and non-premium) may offer the potential to positively impact women's health.

Exploring Young Adults' Beliefs About Cigar Smoking by Susceptibility: A Belief Elicitation Study.

INTRODUCTION: Young adults are at risk for cigar smoking, which is associated with cancers and pulmonary and cardiovascular diseases. Little is known about young adults' beliefs about smoking cigarillos, little filtered cigars, and large cigars, and how these beliefs may vary across cigar types and by cigar susceptibility. AIMS AND METHODS: The larger study surveyed a U.S. sample of young adults (18-30 years old) who never used tobacco products (n = 948) through Qualtrics online panel services in August 2021-January 2022. We assessed participants' susceptibility to using different cigar types. Participants were randomly assigned to open-ended questions about one of the three cigar types to elicit behavioral, normative, and control beliefs. We conducted thematic analysis to code emergent themes within each belief and examined the frequency of reported themes at the intersection of cigar type and cigar susceptibility. RESULTS: Cigar susceptible participants reported positive behavioral beliefs (eg, anticipated relaxation, mood regulation, being cool), friends as supportive referents, and easy-to-smoke control beliefs (eg, high accessibility, low cost) more frequently than non-susceptible participants. Varied frequency by cigar type also emerged. For example, cigarillo and little filtered cigar features were mentioned more frequently as easy-to-smoke control beliefs, while low accessibility was reported more frequently as a hard-to-smoke control belief for large cigars. CONCLUSIONS: Findings identify salient beliefs about cigarillo, little filtered cigar, and large cigar smoking among young adult tobacco never-users. Future research should investigate the potential importance of these beliefs in cigar smoking susceptibility and initiation among young adults, and their potential utility in prevention research. IMPLICATIONS: This thematic analysis identified salient beliefs about cigarillos, little filtered cigars, and large cigars among a U.S. young adult sample, and differentiated emergent beliefs by cigar susceptibility status and by cigar type. Given the lack of cigar smoking prevention media campaigns, identifying these beliefs is the one of the first steps in developing effective cigar smoking prevention strategies. Future quantitative studies are needed to confirm the relationships between these beliefs and smoking initiation of each cigar type to further inform the types of beliefs to be targeted in strategic communication and help prevent cigar smoking initiation among susceptible young adults.

Cardioprotective effects of Baccharis trimera (Less) DC in a rodent model of hookah, alcohol, and energy drink exposure / Efectos cardioprotectores de Baccharis trimera (Less) DC en un modelo de roedor de exposición a narguile, alcohol y bebidas energéticas

This study proposes an unpreceded model of cardiovascular disease by combining alcohol and energy drink intake with hookah smoking to investigate the cardiovascular effects of Baccharis trimera (Less.) DC., a medicinal plant used to treat dyslipidemia. For 10 weeks, Wistar rats (n=8) received alcohol (10% ad libitum) and energy drink (2 mL/kg) and/or were exposed to hookah smoke (1 hour/day). In the last 4 weeks, the animals received daily treatment with vehicle (filtered water) or ethanol soluble fraction of B. trimera (30, 100 and 300 mg/kg). Electrocardiography was performed. Systolic, diastolic, and mean blood pressure, heart rate, and plasmatic cholesterol, triglycerides, urea, creatine, aspartate, and alanine aminotransferase levels were determinate. The heart, aorta, and kidneys were histopathological evaluated. In isolation the risk factors altered all the evaluated parameters and when the risk factors were associated, a synergistic effect was observed. Treatment with B. trimera reversed these cardiovascular changes.

Este estudio propone un modelo sin precedentes de enfermedad cardiovascular mediante la combinación de la ingesta de bebidas energéticas y alcohol con fumar narguile para investigar los efectos cardiovasculares de Baccharis trimera (Less.) DC., una planta utilizada para tratar la dislipidemia. Durante 10 semanas, las ratas Wistar recibieron alcohol (10%) y bebida energética y/o fueron expuestas al humo de narguile. En las últimas 4 semanas, los animales recibieron tratamiento con vehículo, fracción soluble en etanol de B. trimera (30, 100, 300 mg/kg). Se realizó electrocardiografía. Se determinaron los niveles de presión arterial sistólica, diastólica y media, frecuencia cardíaca, colesterol plasmático, triglicéridos, aspartato y alanina aminotransferasa, urea y creatina. El corazón, la aorta y los riñones fueron evaluados histopatológicamente. De forma aislada los factores de riesgo alteraron todos los parámetros evaluados y cuando se asociaron los factores se observó un efecto sinérgico. El tratamiento con B. trimera revirtió estos cardiovasculares cambios.

Correlates of behavior change intents in response to a hypothetical flavored cigar sales restriction among U.S. adult flavored cigar smokers.

Flavored cigar sales restrictions (FCSRs) may reduce cigar smoking and protect public health. This study examined the correlates of behavior change intents in response to a hypothetical FCSR. Data were from a nationally representative sample of adult flavored cigar smokers (ages ≥21; n = 343) collected through an online survey in 2021. Respondents selected their behavior change intents in response to a hypothetical FCSR, including (1) quitting cigars altogether; (2) smoking plain or non-flavored cigars; (3) smoking other flavored tobacco products; (4) smoking cannabis; and (5) other options. Weighted logistic regressions were used to examine the associations of socio-demographic backgrounds, tobacco use history, and tobacco dependence with behavioral change intents. In response to an FCSR, 15.1% of respondents would quit smoking cigars altogether, 41.6% would smoke plain cigars without flavors, 33.4% would substitute flavored cigars with other flavored tobacco products, and 29.2% would substitute flavored cigars with cannabis. Large cigar smokers and blunt smokers were less likely to quit cigars altogether than non-smokers of those products; females and racial/ethnic minorities were more likely to substitute flavored cigars with other flavored tobacco and cannabis products, respectively, than males and non-Hispanic White respondents. Results suggest that FCSRs may reduce cigar smoking among a portion of U.S. flavored cigar smokers while leaving more continuing to smoke plain cigars or transitioning to use other flavored tobacco products or cannabis. Implementing FCSRs should be accompanied by comprehensive flavored tobacco sales restrictions, cessation programs, and educational messages aimed at reducing the use of cigars and other substances.

Exploring the Experiences and Perceptions of Cigar Craving and Addiction among Young Adult Black Cigar Smokers.

Black young adults have the highest prevalence of cigar smoking in the U.S. Little is known about how this population perceives addiction to cigar smoking, which may influence long-term smoking and cessation outcomes. This study used semi-structured in-depth interviews to understand cravings, triggers, and perceived addiction from cigar smoking among a purposive sample of Black young adult cigar smokers (N = 40; 21-29 years). An iterative process was used to develop the codebook, and thematic analysis was used to capture findings based on the products predominantly used: cigarillos, large cigars, or blunts. Results suggest that while participants may share similar types of cravings and triggers (e.g., stress) across the use of these products, predominant blunt smokers reported more unique triggers related to relieving physical discomforts. While most participants reported cigars could be addictive to people in general, only a few perceived that they themselves were addicted. Participants who predominantly smoked cigarillos reported high perceived addiction to cigars, while those who predominantly smoked blunts reported low addiction. Education messages are needed to inform young Black adult cigar smokers about the risks and health symptoms of cigar addiction. These efforts may help increase cigar cessation seeking and reduce cigar addiction-related health consequences and disparities among Black populations.

COMPARISON OF PREVALENCE OF TOBACCO USE AMONG YOUNG PEOPLE IN DIFFERENT COUNTRIES.

OBJECTIVE: The aim: The prevalence analysis of three ways of tobacco use among young adults: traditional (smoking of cigarillos or cigars) and alternative (hookah smoking and use of E-cigarettes) as well as the development of ways of tobacco smoking prevention. PATIENTS AND METHODS: Materials and methods: Cross-section anonymous survey among young adults 18-44 years of age (n=410) has been conducted. The obtained results were compared with the data of the similar studies from different countries. The statistical methods (analysis of the mean and relative values), structural and logical analysis and systemic approach. RESULTS: Results: Among those who were interviewed, aged 18-44 years, there are 24.15±2.11 % of respondents - hookah smokers, 9.02±1.42 % persons prefer the traditional method of tobacco use (smoking of cigarillos or cigars), while 6.34±1.20 % ones use E-cigarettes. Such forms of smoking are more common among males. The smokers of cigarillos, cigars and hookahs have appreciated their high availability when buying - 9 (7;10) points out of 10 possible. The study has found that 11.54±1.58 % of smokers of E-cigarettes and 8.08±1.35 % of hookah smokers consider them safe types of smoking and harmless to their health. CONCLUSION: Conclusions: The prevention methods of smoking prevalence among young people must be based on the tougher rules of tobacco market and latest devices for smoking at the legislative level.

U.S. Trends in Age of Cigar Smoking Initiation by Race/Ethnicity and Education.

INTRODUCTION: Younger age of initiating cigar smoking is associated with greater nicotine dependence and current use. Age of initiating cigarette smoking has increased over time, whereas trends in age of initiating cigar smoking remain understudied. These trends were examined by race/ethnicity, by education, and at their intersection. METHODS: The analytic sample included U.S. Hispanic, Black, and White cigar-ever-smokers aged 24‒25 years (n=29,715) from the 2002‒2019 National Survey on Drug Use and Health. Participants reported their age, race/ethnicity, sex, education (≤high school; some college; ≥bachelor's degree), age of initiating cannabis use, and cigar smoking. Weighted multivariable linear regressions adjusted for sex and age of cannabis use initiation were used to examine trends in age of initiating cigar smoking by race/ethnicity, education, and education Χ year interactions within racial/ethnic groups. Age of initiating cigar smoking comparisons across race/ethnicity and education were examined using the most recent 2019 data. RESULTS: During 2002‒2019, across education, White cigar-ever-smokers started smoking cigars at an older age, whereas it remained unchanged among Hispanic cigar-ever-smokers. Among Black cigar-ever-smokers, age of initiating cigar smoking did not change among those with ≤high school and some college, and was older among those with ≥bachelor's degree. In 2019, age of initiating cigar smoking did not vary by educational level among Hispanic and White cigar-ever-smokers. Black cigar-ever-smokers with ≥bachelor's degree initiated cigar smoking at older ages than their White counterparts. CONCLUSIONS: Black individuals experienced widening education-related disparities, and Hispanic individuals had no progress in delaying age of initiating cigar smoking. Regulatory action banning cigar flavors may impact these trends.